Lipomatous Metaplasia Enables Ventricular Tachycardia by Reducing Current Loss Within the Protected Corridor

Xu, Lingyu; Khoshknab, Mirmilad; Berger, Ronald D.; Chrispin, Jonathan; Dixit, Sanjay; Callans, David J.; Marchlinski, Francis E.; Zimmerman, Stefan L.; Han, Yuchi; Trayanova, Natalia A.; Desjardins, Benoı̂t; Nazarian, Saman

doi:10.1016/j.jacep.2022.07.005

Cited by 16 publications

(25 citation statements)

References 29 publications

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“…Of 421 corridors of viable myocardium computed to traverse LGE, 20 corridors were removed from analysis due to ICD lead artefact on the septum on cardiac CT, which prohibited LM analysis (see Supplementary material online , Table S1 ). Similar to previously reported data from a smaller subset of the cohort, 11 98 out of 102 (96%) critical VT corridors traversed through or were adjacent to LM ( Figure 2, C1 ), while 272 out of 299 (91%) non-critical corridors were distant from LM ( Figure 2, C2 ). 11 Among corridors critical for VT, which traversed LM, 95 had ARI measurements at successive points along the corridor ( Figure 2, A1– C1 ) with longer ARI mean [355 (319–397) vs. 302 (277–333) ms, P < 0.001] and higher ARI SD [61 (35–78) ms vs. 38 (21–60) ms, P < 0.001], when compared with 117 non-critical corridors distant from LM ( Table 3 , Figure 2F ).…”

Section: Resultssupporting

confidence: 87%

“…Similar to previously reported data from a smaller subset of the cohort, 11 98 out of 102 (96%) critical VT corridors traversed through or were adjacent to LM ( Figure 2, C1 ), while 272 out of 299 (91%) non-critical corridors were distant from LM ( Figure 2, C2 ). 11 Among corridors critical for VT, which traversed LM, 95 had ARI measurements at successive points along the corridor ( Figure 2, A1– C1 ) with longer ARI mean [355 (319–397) vs. 302 (277–333) ms, P < 0.001] and higher ARI SD [61 (35–78) ms vs. 38 (21–60) ms, P < 0.001], when compared with 117 non-critical corridors distant from LM ( Table 3 , Figure 2F ). We observed that a corridor ARI mean ≥ 362 ms discriminates corridors critical for VT re-entry, with sensitivity of 0.86 and specificity of 0.89.…”

Section: Resultssupporting

confidence: 87%

“…Notably, the former study focused on the ARI of isthmus vs. bystander scar sites, whereas our study compared the ARI of critical vs. non-critical corridors within infarct zone. Our tissue-specific findings are consistent with Callans and Donahue’s conclusion that the ARIs of VT isthmus (within scar or BZ but close to LM 11 ) are shorter than the ARI of EAM points within low voltage zones (dense scar or LM). The current study expands on prior reports by showing that the ARI of critical VT corridors traversing through or near LM is longer than that of non-critical VT corridors distant from LM.…”

Section: Discussionsupporting

confidence: 92%

“…We have previously shown that most corridors critical for VT re-entry traverse through or near LM. 11 Corridors extracted from LGE that traversed through or near LM on CT, exhibited prolonged ARI and higher ARI dispersion compared with corridors distant from LM, consistent with the observation that ARI in BZ-LM tissue is prolonged compared with BZ-scar tissue.…”

Section: Discussionsupporting

confidence: 81%

“…The patient recruitment, CMR and CT image acquisition and analysis protocols, image registration to electroanatomic mapping (EAM) methodology, electrophysiological study, and ablation strategy and statistical analyses for the INFINITY study have been previously reported. 11 The latter methodologies together with the details related to the calculation of ARI from intracardiac unipolar electrograms and regional ARI dispersion, can be found in Supplemental material.…”

Section: Methodsmentioning

confidence: 99%

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Lipomatous metaplasia prolongs repolarization and increases repolarization dispersion within post-infarct ventricular tachycardia circuit cites

Zahid

Khoshknab

et al. 2022

EP Europace

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Aims Post-infarct myocardium contains viable corridors traversing scar or lipomatous metaplasia (LM). Ventricular tachycardia (VT) circuitry has been separately reported to associate with corridors that traverse LM and with repolarization heterogeneity. We examined the association of corridor activation recovery interval (ARI) and ARI dispersion with surrounding tissue type. Methods and results The cohort included 33 post-infarct patients from the prospective Intra-Myocardial Fat Deposition and Ventricular Tachycardia in Cardiomyopathy (INFINITY) study. We co-registered scar and corridors from late gadolinium enhanced magnetic resonance, and LM from computed tomography with intracardiac electrogram locations. Activation recovery interval was calculated during sinus or ventricular pacing, as the time interval from the minimum derivative within the QRS to the maximum derivative within the T-wave on unipolar electrograms. Regional ARI dispersion was defined as the standard deviation (SD) of ARI per AHA segment (ARISD). Lipomatous metaplasia exhibited higher ARI than scar [325 (interquartile range 270–392) vs. 313 (255–374), P < 0.001]. Corridors critical to VT re-entry were more likely to traverse through or near LM and displayed prolonged ARI compared with non-critical corridors [355 (319–397) vs. 302 (279–333) ms, P < 0.001]. ARISD was more closely associated with LM than with scar (likelihood ratio χ2 50 vs. 12, and 4.2-unit vs. 0.9-unit increase in 0.01*Log(ARISD) per 1 cm2 increase per AHA segment). Additionally, LM and scar exhibited interaction (P < 0.001) in their association with ARISD. Conclusion Lipomatous metaplasia is closely associated with prolonged local action potential duration of corridors and ARI dispersion, which may facilitate the propensity of VT circuit re-entry.

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Section: Resultssupporting

confidence: 87%

Section: Resultssupporting

confidence: 87%

Section: Discussionsupporting

confidence: 92%

Section: Discussionsupporting

confidence: 81%

Section: Methodsmentioning

confidence: 99%

See 3 more Smart Citations

Lipomatous metaplasia prolongs repolarization and increases repolarization dispersion within post-infarct ventricular tachycardia circuit cites

Zahid

Khoshknab

et al. 2022

EP Europace

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Exploring the Full Potential of Radiofrequency Technology: A Practical Guide to Advanced Radiofrequency Ablation for Complex Ventricular Arrhythmias

Tonko,

Lambiase

2024

Curr Cardiol Rep

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Purpose of Review Percutaneous radiofrequency (RF) catheter ablation is an established strategy to prevent ventricular tachycardia (VT) recurrence and ICD shocks. Yet delivery of durable lesion sets by means of traditional unipolar radiofrequency ablation remains challenging, and left ventricular transmurality is rarely achieved. Failure to ablate and eliminate functionally relevant areas is particularly common in deep intramyocardial substrates, e.g. septal VT and cardiomyopathies. Here, we aim to give a practical-orientated overview of advanced and emerging RF ablation technologies to target these complex VT substrates. We summarize recent evidence in support of these technologies and share experiences from a tertiary VT centre to highlight important “hands-on” considerations for operators new to advanced RF ablation strategies. Recent Findings A number of innovative and modified radiofrequency ablation approaches have been proposed to increase energy delivery to the myocardium and maximize RF lesion dimensions and depth. These include measures of impedance modulation, combinations of simultaneous unipolar ablations or true bipolar ablation, intramyocardial RF delivery via wires or extendable RF needles and investigational linear or spherical catheter designs. Recent new clinical evidence for the efficacy and safety of these investigational technologies and strategies merits a re-evaluation of their role and clinic application for percutaneous VT ablations. Summary Complexity of substrates targeted with percutaneous VT ablation is increasing and requires detailed preprocedural imaging to characterize the substrate to inform the procedural approach and selection of ablation technology. Depending on local experience, options for additional and/or complementary interventional treatments should be considered upfront in challenging substrates to improve the success rates of index procedures. Advanced RF technologies available for clinical VT ablations include impedance modulation via hypotonic irrigation or additional dispersive patches and simultaneous unipolar as well as true bipolar ablation. Promising investigational RF technologies involve an extendable needle RF catheter, intramyocardial RF delivery over intentionally perforated wires as well as a variety of innovative ablation catheter designs including multipolar linear, spherical and partially insulated ablation catheters.

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The Use of Pre- and Peri-Procedural Imaging During VT Ablation

Whitaker,

Rajani,

Ismail

et al. 2024

Curr Treat Options Cardio Med

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Purpose of review Ventricular arrhythmias, including ventricular tachycardia (VT), ventricular fibrillation (VF), and premature ventricular complexes (PVCs), may occur in structurally normal hearts and in the context of structural heart disease. In those patients with recurrent arrhythmias despite medical therapy, catheter ablation may be considered. To successfully suppress ventricular arrhythmias, an understanding of the substrate for the arrhythmias is crucial. Recent findings Advances in cross-sectional imaging used prior to VT ablation permit accurate localisation of fibrosis that represents the substrate for VT, allowing an operator to focus the electrophysiologic assessment during a procedure and effectively target all relevant parts of the substrate. In addition, the use of imaging during a procedure allows registration of pre-procedural cross-sectional imaging as well as real-time substrate assessment and allows the operator to visualise tissue-catheter contact for the most effective lesion delivery. Summary In this review, the role of pre-procedural cardiac computed tomographic (CCT) imaging and cardiovascular magnetic resonance (CMR) imaging and the peri-procedural use of intra-cardiac echocardiography (ICE) are discussed.

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Lipomatous Metaplasia Enables Ventricular Tachycardia by Reducing Current Loss Within the Protected Corridor

Cited by 16 publications

References 29 publications

Lipomatous metaplasia prolongs repolarization and increases repolarization dispersion within post-infarct ventricular tachycardia circuit cites

Lipomatous metaplasia prolongs repolarization and increases repolarization dispersion within post-infarct ventricular tachycardia circuit cites

Exploring the Full Potential of Radiofrequency Technology: A Practical Guide to Advanced Radiofrequency Ablation for Complex Ventricular Arrhythmias

The Use of Pre- and Peri-Procedural Imaging During VT Ablation

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